Become a Volunteer: Quad-Cities Campus

To get involved as a health care volunteer at Trinity, please complete the form below. After your application is completed, someone from Volunteer Services will contact you regarding your application.

Teens: A limited number of high school students (ages 15 - 18) may be considered for our program. Teens
should not fill out this application. Apply in person by calling (309) 779-2211.

(Note: This volunteer application is to volunteer at our Trinity Quad-Cities Campuses. If you wish to become a volunteer at Trinity Muscatine, contact Lea Ann Logel at (563) 263-1926 or via email leaannlogel@machlink.com .)

Warning: any information entered on this form is not encrypted and we cannot guarantee its security in transmission.  Please do not include any sensitive health information in this form.  If you prefer, you can contact us at (309) 779-2211.

Title (Mr./Ms./Mrs.):
* Last Name:
* First Name:
* Middle Initial:
* Address:
Address line 2:
* City:
* State:
* Zip:
* Home phone:	() -Second partThird part
* Cell phone:	() -Second partThird part
* Date of birth:	Date and time
* Email address:

 
Current Status

* Current status:
College student (enter name/location of college in space below) Paid work part time (enter employer and description in spaces below) Paid work full time (enter employer and description in spaces below) Not currently employed Homemaker Retired
Name and location of college being attended currently:
Please give name of current employer:
Please describe the duties you perform in your current job:

 
Please name your former employers, type of work, and your approximate dates of employment (most recent first)

Past Employer (1)
* Name:
* Type of work:
* Dates:
Past Employer (2)
* Name:
* Type of work:
* Dates:

 
Hobbies and Skills

* List hobbies, club memberships, civic involvement, special talents or skills:

 
Volunteer Experience

Please list any previous volunteering experience:

* Type of volunteer experience you prefer (check one or more):

Work in patient areas Gift shop Clerical Occasional one-time projects

* Preferred campus for volunteering (check one or more):

Trinity Rock Island Trinity Moline Trinity Bettendorf

 
Miscellaneous

* Days and times you may be available to volunteer:	weekday mornings 8-12 weekday afternoons 12-4
* List any scheduling restrictions for volunteer work (example: "No Thursdays"):
* List any physical limitations for volunteer work (examples: "vision or hearing impairment"):
* Have you ever been convicted of a crime?:	YesNo
* Do you have a record of founded child or dependent adult abuse?:	YesNo

 
List names, addresses, and phone numbers of two references (persons who are not related to you, have known you for at least five years, and have given permission to use their names.)

Reference (1)
* Name:
* Address:
* City, State, Zip:
* Phone:	() -Second partThird part
Reference (2)
* Name:
* Address:
* City, State, Zip:
* Phone:	() -Second partThird part

 
Your signature below indicates that the information is true and accurate. I acknowledge that if any answer or information is not true, accurate or complete, I may not be chosen to volunteer; or if chosen, I may be discharged.

* Signature:
* Date:	Date and timeNow
	I have read and agree to the HIPPA Patient Authorization and give consent for use and/or release of my health information provided in this form.
* Security Code:

Becoming a Trinity volunteer involves a personal interview, orientation, and training. Please be aware that this process can take from 2-8 weeks after application is received. Volunteers for summer only should apply in early spring.